[1802]
On january 8, 1993, at approximately 9:30 p. M. , the post si=urgical patient in room 3147 called the nurse. This patient was on bed rest at 45 degree upright position and called the nurse to complain that while asleep, the bed lowered to horizontal position all by itself. Upon examination by the physician, the patient ws presented with broken sutures and oozing blood from surgical area which required immediate surgical intervention. Although this incident was unwitnessed, the hillrom bed was immediately removed from the patient care area and sent to maintenance for repair. The maintenance engineer assigned to repairing all beds from the patient care areas discovered that not just one but, two of the hill rom 840 beds had electrical problems in the head controldevice not labeled for single use. Patient medical status prior to event: invalid data. There was not multiple patient involvement. Device serviced in accordance with service schedule. Date last serviced:. Service provided by: user facility biomedical/bioengineering department. Service records available. No imminent hazard to public health claimed. Device used as labeled/intended. Device was evaluated after the event. Method of evaluation: invalid data. Results of evaluation: component failure. Conclusion: invalid data. Certainty of device as cause of or contributor to event: invalid data. Corrective actions: device repaired and put back in service. Invalid data - on device destroyed/disposed of status.
Patient Sequence No: 1, Text Type: D, B5